Study finds room for improvement in identification and treatment of stroke patients

July 12, 2012—The number of stroke deaths is declining in Ontario and the rest of Canada, due in part to better management and treatment of the disease. However, a new study released today by the Canadian Institute for Health Information (CIHI) shows that there may still be room for improvement in the early diagnosis and treatment of stroke patients. For example, the study found that about 1 in 10 Ontario stroke patients seen in a hospital emergency department (ED)—representing more than 5,000 cases over a four-year-period—was documented as having had a stroke only after being admitted to a hospital ward.

The study found that these patients had no stroke or stroke symptoms (such as headache or dizziness) listed on their ED records and were less likely to have received a brain imaging scan during the course of their emergency stay than other stroke patients. Best practice recommends that suspected stroke patients should receive brain scans within one hour of their arrival in the ED to identify the type of stroke and appropriate course of treatment.

“Carrying out rapid assessments and confirming that a person has had a stroke most often begin in the ED. It is a coordinated effort among many providers and can present a challenge,” explains Dr. Paul Ellis, emergency physician at the University Health Network. “But the earlier this is done, the sooner appropriate treatment can begin and the greater the chances a patient can recover.”

CIHI’s study, Pathways of Care for People With Stroke in Ontario, examined more than 62,000 stroke cases that occurred in the province between 2006–2007 and 2009–2010. The study was limited to Ontario because it is the only province with comprehensive stroke data available to CIHI across various care settings. By following how stroke patients move through the system, the study identified the most common pathways of care for these patients and sheds light on important transition points in their journey. It also facilitates an evaluation of how well the system is integrated and functions for patients.

“Research has shown that early identification of stroke symptoms and treatment of stroke are crucial to improving a patient’s chance for recovery,” says Jeremy Veillard, Vice President, Research and Analysis, CIHI. “While Ontario has made significant progress in improving stroke care, there are still gaps in what we know about how stroke care compares among provinces and how it is delivered outside of hospital settings. Better and more comparable data in this area could help shed further
light on which follow-up care strategies deliver the best results for stroke patients.”

Timeliness of transitions between care settings

CIHI’s study identified potential delays in follow-up care for some stroke patients discharged from acute care hospitals. Nearly one in five (18%) stroke inpatients spent at least five days in an alternate level of care (ALC). This means that they were occupying an acute care hospital bed while waiting
to be transferred to a more appropriate care setting, most often complex continuing care, inpatient rehabilitation or long-term care. On any given day during the four-year study period in Ontario, an average of 179 stroke patients were in ALC beds; waits were longest for patients transferring to a long-term care bed, with an average stay of almost six weeks in ALC.

“Extended hospital stays may increase a patient’s risk of complications, such as infections or bed sores, and may delay access to more appropriate treatment,” says Kathleen Morris, CIHI’s Director of Health System Analysis and Emerging Issues. “Research shows that timely access to rehabilitation programs, services and facilities are important to provide a stroke patient with the best chance at recovery.”

The study’s findings show that 29% of Ontario stroke patients who were hospitalized in acute care were transferred to inpatient rehabilitation, which represents a higher rate of transfer than is generally seen elsewhere in Canada. Best practice recommends that all patients with moderate or severe stroke who are ready for rehabilitation and have rehabilitation goals should be given an opportunity
to participate in inpatient stroke rehabilitation. Of those admitted to inpatient rehabilitation, the study found proportionately fewer patients with severe disability (26%) than those assessed as mildly impaired (47%) and moderately impaired (28%).

Ambulance services: the most appropriate response to signs or symptoms of stroke is to call 9-1-1

The study also found room for improvement in the ability of the population to recognize and respond most appropriately to the first symptoms of stroke. Despite best practice recommendations, more than one in three Ontario stroke patients did not arrive at the hospital by ambulance. Understanding the warning signs and symptoms of stroke and immediately contacting emergency medical services when needed can lead to better outcomes for stroke patients. Ontario paramedics have protocols in place
to screen for stroke events, help ensure people get to an appropriate hospital and notify facilities in advance to activate stroke protocols within their EDs.

About CIHI

Established in 1994, CIHI is an independent, not-for-profit corporation that provides essential information on Canada’s health system and the health of Canadians. Funded by federal, provincial and territorial governments, CIHI is guided by a Board of Directors made up of health leaders across the country. Our vision is to improve Canada’s health system and the well-being of Canadians by being a leading source of unbiased, credible and comparable information that will enable health leaders to make better-informed decisions.